Psychotherapy Paradigms in Schizophrenia: Trapped in Nightmares – II

Nightmares occur rather during the three stages of successively deeper sleep, and stage four, the period of deepest sleep, is also the period of the most severe nightmares. The nightmare is described as a massive failure of ego functioning, from which the subject awakens with a bloodcurdling scream, dissociated, confused, hallucinating, and unresponsive to the environment. Perhaps, then, our statement that the schizophrenic patient falls precipitously, catastrophically, from one level of functioning to another, into an abyss, and that many of his symptoms manifest his struggle to awaken from a nightmare in which he feels trapped. Here’s the second part of the eight-part serialisation of Prof. Ashoka’s lecture, wherein he deals with the practical aspects of psychotherapy, in the weekly column, exclusively for Different Truths.

Almost immediately after preparing this lecture, I came across an allusion to the 19th Freud Anniversary Lecture of the New York Psychoanalytic Institute by Charles Fisher, who reports research purporting to make the astonishing discovery that nightmares do not occur during REM sleep (a stage of light sleep associated with ordinary dreaming, from which it is relatively easy to awaken). Nightmares occur rather during the three stages of successively deeper sleep, and stage four, the period of deepest sleep, is also the period of the most severe nightmares. The nightmare is described as a massive failure of ego functioning, from which the subject awakens with a bloodcurdling scream, dissociated, confused, hallucinating, and unresponsive to the environment. Perhaps, then, our statement that the schizophrenic patient falls precipitously, catastrophically, from one level of functioning to another, into an abyss, and that many of his symptoms manifest his struggle to awaken from a nightmare in which he feels trapped, is more than a mere figure of speech.

All of us have some knowledge of nightmares. In looking at our own experience in this auditorium, we have touched, though ever so lightly, upon the elements of psychosis. I want to emphasise that the schizophrenic person has no experience of which we are incapable. Perhaps his functioning is more precarious, more susceptible to prolonged, disastrous interruption, than yours or mine, but he knows nothing that we are forever deprived of understanding. That we are more efficient than he is guarding against such interruptions and recovering from them is certainly useful to us in many situations, although it is not an unmixed blessing when it comes to our attempts to treat schizophrenic persons. Then, our zeal and efficiency in protecting ourselves from such states as we have glimpsed in this hour may work to separate us from the schizophrenic person for whom we care. We cannot tolerate him as a man, in part because of the possibilities of which he reminds us of ourselves. So he must become a thing upon which we operate. In your professional careers, you will have to judge for yourselves when assertions of the certainty of an organic defect in schizophrenia are essentially assertions that nothing so strange can be related to experience as you or I know it. I regret to inform you that decisions to treat the physiological organism with electricity or drugs too often, it seems to me, involve the effort to ignore or suppress symbolizations (not necessarily verbal) of states we physicians cannot stand. In psychotherapy, we psychotherapists may withdraw—I use the word advisedly—into a professional role, replete with diagnostic and psychodynamic terms: just listen to the average case presentation! A psychotherapist may offer pontifical “interpretations”—the very word may be used in a way to suggest his distance from his patient—while the therapist, of course, at the same time attributes the untoward effects of such interpretations to the inability of the schizophrenic patient to make use of psychotherapy aiming at insight because of a “defective” ego. In the same way, the psychotherapist may bestow kindly forbearance, indulgence, and the ubiquitous “management,” as if he were training a benighted member of a subhuman species.

Do you remember the emphasis in the first conception of schizophrenia on the narcissism of the schizophrenic person, his self-absorption, his withdrawal from others? I urge you to observe for yourselves, paying careful attention to the subtle nuances by which one person indicates he has removed himself from another, when a psychotherapist, family member, nurse, or friend complains of that notorious difficulty in maintaining a relationship with a schizophrenic person: who, in fact, withdraws from whom?

Ladies and gentlemen, I know that one question is the most important to you. Do our conceptions of schizophrenia, for example, in fact, help us to care for the schizophrenic person? Of course, I would like to convince you—I am always engaged in the effort to convince myself—that psychotherapeutic treatment in psychiatry has some elements of rationality; that is, that at the least our care of the patient bears some meaningful relation to our conception of what ails him. Ideally, we should be able to demonstrate that the psychotherapy of schizophrenia addresses itself to the elimination of the etiologic or pathogenic event, to the mitigation of the morbid process, or to the support of the reparative efforts that are the personality system’s own response to the morbid process. As you will already have anticipated, I am going to wander about a bit during this lecture, but what guides me through the maze of my own thoughts is the effort to clarify the state of affairs we conceive as schizophrenia, the state of affairs we wish to bring about through psychotherapy, and in what ways psychotherapy is an adequate means to transform one state of affairs into the other.

Those of you who have not worked with a schizophrenic patient, imagine you face your first such patient. He walks with a curious mixture of diffidence and arrogance into the emergency room, the examining room, your office. He is wearing a heavy jacket, which he does not remove when he sits down. He glances at you, looks away; he may smile to himself; you have a fleeting and hardly comfortable impression that he knows something he is not telling. He says nothing. Now what? You are about to say something. What will you say? What will happen between the two of you during that first meeting? Perhaps you comfort yourself that in such an inexact field, involving such gross transactions, you are permitted a wide margin of error. I have been haunted from time to time by the conviction that clumsiness in symbolic activity, such as psychotherapy involves, is as fateful for the future of treatment as the slip of a surgeon’s knife. That suggests we should know at least as much about ourselves as symbolising beings, about the meanings of what we express and how we express such meanings, as the surgeon knows about his hand and knife.

(To be continued)

©Prof. Ashoka Jahnavi Prasad

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